Polio Australia encourages every polio survivor living in Australia (whether you contracted polio in Australia or overseas) to join the Australian Polio Register. Our strength lies in our numbers – please help us to get you the services you need by completing the form below.
You can also download a PDF version of the Australian Polio Register Form if you (or a family member / friend without internet access) would prefer to complete the form by hand and mail it to: Polio Australia, PO Box 500, East Kew Vic 3102.
Before completing the Australian Polio Register Form please check this page to make sure that you haven’t already submitted a Registration (be aware that an existing entry will only appear on that page if you have previously given Polio Australia permission to publish your polio details). Note that the only way to include your details on the Register is via the online or downloadable forms on this page – being a member of a State Polio Network or a local Polio Support Group, or accessing a polio service (such as Polio Services Victoria), does not automatically add your details to the Register.
* indicates a required field
After submitting the form you should see a message in a box with a green border saying “Your registration was submitted successfully. Thanks.”, and you will be re-directed to a “thank you” page. If you instead receive a “validation errors occurred” message, please check your entries – particularly ensuring that all required questions (those marked with *) have been answered – then resubmit the form.
If you strike a difficulty in submitting this form that you cannot resolve, you can download a PDF version of the Australian Polio Register Form to complete and mail to Polio Australia. You can also contact us by phone or email, or by completing our contact form, to let us know about the difficulty you experienced.